4 de octubre de 2010

Infantes salvos en "la botella"

Weighing the Lives of Babies in HaitiBy

DENNIS ROSEN, M.D.

It was the first week of May, almost four months after the earthquake, and the situation remained dire. Rubble was everywhere, many buildings were unusable, and all of the pediatric care was being given in tents. Supplies were sparse and unreliable.

The obstetricians at the General were on strike, and women in labor were being told to go elsewhere. But word had gotten out that there were American doctors at the hospital, and many patients simply refused to leave.

So it was on that rainy Sunday evening that there were six women in active labor in the emergency room. And soon one of them, in her late teens, gave birth to a tiny boy, just 2 pounds 3 ounces. A neonatologist on our team estimated that he was two months premature. (The mother claimed she hadn’t even known she was pregnant.)

Premature babies can get into a lot of trouble, and the smaller they are, the higher their risk of complications. They usually have difficulty maintaining a normal body temperature, losing heat to their surroundings faster than they can generate it. This is why they are kept in incubators until they are able to stay warm on their own. They are at high risk for infections, along with feeding and breathing problems.

Once the baby was born, we dried and swaddled him and started looking for a place where he could be cared for until he was stable enough to be sent home. There were no working incubators at the hospital, nor any free beds in the pediatric tents, and we had no luck finding incubators at other hospitals.

Then an American physician at another medical camp told us that he had faced a similar situation some days before, and had built his own incubator — “MacGyver” style, as he put it. He suggested we do the same.

So that’s what we did. We took a cardboard box from the medical supply room, padded it with some surgical drapes and a blanket and found a desk lamp with a working bulb to serve as a source of heat. Voilà! Our youngest patient now had an incubator.

The next morning we tried to persuade the attending Haitian pediatrician to accept the baby to the pediatric tents. “Don’t be absurd!” she scoffed, as I recall. “A baby that small will not make it. He has no chance of survival, and we have no spare beds to waste.”

None of us felt comfortable arguing with her. Still, we knew that to send the baby to his mother’s tent city while he was still so vulnerable would be a death sentence. So we decided to keep him and his mother in the emergency room until a proper place could be found — understanding that we needed to find a solution before returning to Boston, as the group that would follow us did not include pediatricians qualified to treat complications of prematurity.

A baby bottle was found, along with clothes and diapers. The nurses taught his mother how to express milk into the bottle and to feed him. We’d been calling him “baby in the box”; now he became Jack, as in Jack in the box. He did very well, and his mother, after overcoming her surprise at his unexpected appearance, bonded with and cared for him devotedly.

Each day we pressed his case to the Haitian medical team, and each day we were turned down. “There is no room for him,” we were told, though there seemed to be beds for other children in the pediatric tents.

Finally, on Friday, we found an incubator for him at another hospital. We transferred him and his mother there, satisfied that we had gotten him through those first few days, but soberly aware of the odds he faced going forward. The next day we left for Boston.

Six weeks after our return, at an informal reunion, the neonatologist told us he had learned that Jack had been discharged home with his mother in good health, weighing five and a half pounds.

We were thrilled. Our stubbornness had paid off.

But our euphoria was tempered by a somber reality. Looking at the big picture, we had to concede that the Haitian doctors were probably right.

We were in Port-au-Prince, after all, not Boston. Surely the Haitians, acutely aware of what they could and could not do with the resources they had, would know better than a group of well-intentioned foreigners accustomed to the best equipment money can buy. Didn’t it make more sense to invest time, effort and scarce resources in a baby with a better chance of surviving?

Yet ultimately this was not an abstract discussion about the proper allocation of medical resources in an impoverished country, but a decision about the fate of a baby who was very much alive. He was our patient, and we were determined to give him the best possible care.

In the little-picture view, a life had been saved.

Dr. Dennis Rosen is a pediatric pulmonologist at Children’s Hospital Boston and an instructor at Harvard Medical School.